The End of “Obamacare?” Yes and No

In this month’s letter, Dr. Rick Valachovic talks with others in the dental community about how the new Congress and the Trump Administration might “repeal and replace” the Affordable Care Act.

Like most Americans who woke on Nov. 9 ill-prepared for the political earthquake that rocked the nation, health policy observers have been scrambling to determine how a Trump Administration will affect health policy in general and oral health specifically. The situation remains extremely fluid, but it’s undeniable that the health policy landscape is about to shift dramatically.

Three weeks after the election, the President-elect made two appointments that offered some clues as to what may lie ahead. While the ACA—considered by many to be President Obama’s signature achievement—may not be dismantled entirely, it is sure to be shaken up and stripped down in the years ahead, and ultimately rewritten to reflect a more limited government role.

Mr. Trump’s nominee to head the Department of Health and Human Services is Representative Tom Price (R-GA), who currently chairs the House Budget Committee. Rep. Price has been trying to repeal the ACA since 2009 and will be the driving force behind renewed efforts. Does that mean that the more than 20 million people now insured thanks to the ACA are about to lose their coverage? Not necessarily.

“I don’t think any administration would be interested in leaving consumers hanging,” Marko Vujicic, Ph.D., Chief Economist and Vice President of the American Dental Association Health Policy Institute, replied when I asked him about the potential consequences of an ACA repeal.

Marko is one of the people at some of our partner organizations with whom I spoke last month. I was pleased to learn that, despite some very real concerns about what the future may hold, these colleagues do not ascribe to the doom-and-gloom scenarios many pundits have put forth in recent weeks.

“The health care positions articulated by the Trump campaign are likely to lead to consumers paying more of the cost of their medical care, which could crowd out dental spending,” Marko told me. On the other hand, he pointed out that the ACA also “missed the boat” in many ways when it came to dental care.

“In whatever form repeal and replace happens,” Marko believes, “it might create an opening—an opportunity to reexamine some of the law’s dental provisions.”

What might a Republican health plan look like? The Empowering Patients First Act, authored by Rep. Price, provides a detailed description of one vision for repealing and replacing the current health care law. The Price plan would repeal Medicaid expansion, which has extended coverage to 15.7 million people and delivered an infusion of federal dollars—$47 billion in the first year alone—to participating states. Despite initial reluctance among many Republican governors to accept the new Medicaid funding, 31 states and the District of Columbia eventually chose to take part, and several more states were on the cusp of applying for waivers to design their own Medicaid expansion programs before the election.

Now those efforts are on hold as everyone waits to see whether the new Congress will repeal the expansion or modify the program in other ways. House Speaker Paul Ryan’s proposal, A Better Way, would cut federal funding to states that have already expanded Medicaid rather than eliminate the expansion all together. A third plan, authored by Sen. Ted Cruz (R-TX), is mute on Medicaid expansion.

President-elect Trump’s nominee to head the Centers for Medicare & Medicaid Services (CMS), Seema Verma, M.P.H., will also play a central role in shaping the new administration’s health policy. The Indiana-based consultant is well acquainted with the ACA, having worked with several states participating in the Medicaid expansion to redesign their programs.

Assuming Medicaid continues to play a part in whatever ACA replacement plan emerges, Seema Verma’s work in the past with Indiana governors Mike Pence and Mitch Daniels may provide clues to what lies in store for Medicaid beneficiaries. The Indiana expansion plan required new participants to pay a greater share of their medical costs and mandated the use of health savings accounts. Of special interest to our community, the Indiana plan included adult dental benefits and used access to these benefits as an incentive for Medicaid recipients to make regular contributions to their accounts.

As for Mr. Trump’s views on these matters, more flexible health savings accounts figured prominently in his campaign’s health care platform, so these might well have a place in a redesigned Medicaid program. During the campaign, he also made clear his desire to turn Medicaid as a whole into a block grant program, which would give states more discretion in how they spend federal Medicaid dollars. Some lawmakers have proposed an alternative—a per-capita funding formula. Interestingly, this per-member-per-month strategy would align with some of the accountable care models that are currently being tested by the Center for Medicare & Medicaid Innovation, a creation of the ACA.

Like Marko, Scott Litch, Esq., CAE, Chief Operating Officer and General Counsel at the American Academy of Pediatric Dentistry, also sees room for improvement in how the federal government supports oral health, particularly when it comes to children. When we spoke, he mentioned the perennial problems (high administrative burden and low reimbursement) dentists encounter with Medicaid, and he pointed out that although children’s dental care is a covered benefit under the ACA, many insurance plans offered through the marketplaces include high deductibles. As a result, families end up paying out-of-pocket for their children’s dental care or don’t seek care at all. Scott is also concerned about another ACA “glitch”—the fact that consumers who purchase a children’s medical plan that lacks dental coverage are not required to purchase a stand-alone dental plan for their children.

“In dentistry, the whole idea is to get people into preventive care,” Scott says, noting that the need for out-of-pocket spending discourages such behavior. After the new administration takes office, Scott will be keeping an eye on the future of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Medicaid benefit, which provides comprehensive and preventive health care services for children, as well as on the future of the Children’s Health Insurance Program (CHIP). CHIP, which is set to expire at the end of September 2017, covers children whose parents lack private insurance but earn too much to qualify for Medicaid. Our community will need to make a strong case on behalf of these federal programs if we want them to remain intact in the years ahead.

Children’s dental care is one of the 10 essential health benefits that the ACA specifies must be covered by Medicaid, CHIP and private insurance plans sold through the federal and state health insurance marketplaces. Maternity and newborn care, mental health services and addiction treatment are among the other mandated benefits that make current plans costly. In an effort to make insurance coverage less expensive and more attractive to healthy young consumers, the Price plan would allow insurers to sell plans that lack these essential benefits despite their value to other consumers.

Despite all the talk of wholesale change, repeal of the ACA may prove more of a challenge than the Trump team envisioned. In fact, lawmakers appear to be looking for ways to retain two facets of the ACA that have proven extremely popular: the provision that allows young people to stay on their parents’ policies until age 26, and the provision that prevents insurers from refusing to cover people with pre-existing health conditions. That said, ACA replacement plans could deviate from these provisions in significant ways. Some Republican proposals would allow insurers to charge sick people more if they allow their health coverage to lapse (if, for example, they are too sick to work and can’t afford insurance between jobs). These proposals also rely on high-risk pools to cover people whose health conditions make them unattractive to insure. Rep. Price proposes funding for these pools at $1 billion per year for three years; Speaker Ryan’s plan allocates $2.5 billion per year in perpetuity.

When I spoke with Julie Frantsve-Hawley, she was still digesting the impact the election might have on her association’s agenda. She told me AAPHD members had identified three advocacy priorities for the coming year: Increasing federal funding for oral health, community water fluoridation, and the creation of an adult oral health benefit in Medicare.

“We may need to divert attention from that to maintain ground on some of these other things,” she told me. She plans to engage in conversations with her members and reach out to other oral health stakeholders to evaluate how best to proceed. “I think anything we do needs to be done collectively,” she concluded.

The American Association for Dental Research (AADR) is also focused on federal oral health funding, with an emphasis, not surprisingly, on research dollars. Although President-elect Trump has not made research funding a focus of his first 100 days in office, AADR Executive Director Christopher Fox, D.M.D., D.M.Sc., sees some reasons for optimism on this front. First, candidate Trump mentioned the importance of medical research and innovation during his campaign and also talked about investing in infrastructure.

“We hope that his infrastructure investment includes infrastructure as it relates to the scientific enterprise,” Chris told me.

Second, Chris rightly points out that biomedical research has enjoyed bipartisan support in the past—for its economic value as well as for its impact on the nation’s health. Finally, a fourth dentist, Drew Ferguson (R-GA), was just elected to Congress. Chris believes Dr. Ferguson will help inform his colleagues on Capitol Hill and the new HHS secretary about issues related to dentistry and oral health.

During this time of uncertainty, it’s easy to be fearful. The foundation on which we’ve built our advocacy efforts over the last decade is now riven with cracks, and what will rise in its place is largely unknown. Yet, as Chris put it, “We cannot put our heads in the sand. We need to stay optimistic and treat this as an opportunity.”

I agree. Repealing and replacing the ACA will be a monumental and time-consuming task, as Senate Republicans have acknowledged. The pace of legislative change gives us plenty of opportunities to reach out to the Trump Administration and our Members of Congress to educate them about the value of what we do and the critical role dental care plays in supporting overall health. Members of the dental education community must rally the same energy that propelled us to support health care reform eight years ago if we want a hand in shaping its continued evolution.
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